The role of laser and intense pulsed light in the treatment of hyperpigmentation disorders

Mostafa A Hammam; Eman S Abd Alsalam Tabana

doi:10.4103/1110-2098.178939

REVIEW ARTICLE

Year : 2016 | Volume : 29 | Issue : 1 | Page : 17-21

The role of laser and intense pulsed light in the treatment of hyperpigmentation disorders

Mostafa A Hammam¹, Eman S Abd Alsalam Tabana²
¹ Department of Dermatology and Andrology & STDs, Faculty of Medicine, Menoufia University, Menoufia, Egypt
² Department of Dermatology and Andrology & STDs, Al Mahmoudia Central Hospital, Al Mahmoudia, Behira, Egypt

Date of Submission	02-Jan-2015
Date of Acceptance	26-Feb-2015
Date of Web Publication	18-Mar-2016

Correspondence Address:
Eman S Abd Alsalam Tabana
MBBCh, Al Mahmoudia Central Hospital, Alkwady, Al Mahmoudia, 22511 Behira
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1110-2098.178939

Abstract

Objective
This article reviews the treatment of hyperpigmentation disorders with laser and intense pulsed light (IPL).
Data sources
Previous literatures, reviews, and studies as well as medical websites (PubMed, MD consult, Medscape) and scientific journals databases were searched from the start date of each database.
Study selection
Selection was done by supervisors for studying new advancements in treating hyperpigmented lesions with laser and IPL devices.
Data extraction
In this review data from published studies were manually extracted and summarized. Study quality assessment included determining whether ethical approval was obtained, prospective design, eligibility criteria specified, appropriate controls used, adequate follow-up and defined outcome measures achieved.
Data synthesis
In this review several studies of the role of laser and IPL in treating hyperpigmented lesions were included. There are different laser and IPL devices for treating hyperpigmented lesions with different indications. We got our data from studying the different types of laser and IPL approaches to know which one is preferred taking into consideration different complications of the approaches.
Findings
A total of 44 studies were included in the review as they were deemed eligible by fulfilling the inclusion criteria. Of these 44 articles, included in this review, 32 were laser studies and 12 were IPL studies. Studies indicate that laser and IPL therapy can be effective in the treatment of a wide variety of hyperpigmented skin lesions using the basic principles of selective photothermolysis. A full understanding of laser and IPL principles and the characteristics of the lesion to be treated is essential for the effective and safe use of light-based therapies.
Conclusion
Progress in laser and IPL technology has involved the development of safer and more efficient methods of achieving the desired effects on hyperpigmented skin lesions. The Q-switched lasers with their high peak power and pulse width in the nanosecond range are best suited to treat various epidermal, dermal, and mixed lesions. Long-pulsed ruby and alexandrite lasers have been shown to be effective in the treatment of Q-switched ruby laser-resistant congenital nevi and other pigmented lesions. Nonablative fractional photothermolysis holds great promise in treatment of both pigmentary variation as well as skin textural abnormalities. Intense pulsed technology is a highly versatile, safe, and effective modality for the treatment of pigmented lesions.

Keywords: Hyperpigmentation treatment, intense pulsed light, pigment-specific lasers

How to cite this article:
Hammam MA, Abd Alsalam Tabana ES. The role of laser and intense pulsed light in the treatment of hyperpigmentation disorders. Menoufia Med J 2016;29:17-21

How to cite this URL:
Hammam MA, Abd Alsalam Tabana ES. The role of laser and intense pulsed light in the treatment of hyperpigmentation disorders. Menoufia Med J [serial online] 2016 [cited 2023 Jun 9];29:17-21. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/17/178939

Introduction

Hyperpigmentation is a common and distressing problem frequently encountered in dermatology, with many patients seeking therapies to improve their cosmetic appearance. It is the result of an increase in melanin deposition in the skin either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change depends on the amount and location of the melanin deposition. Epidermal deposition appears as brown discoloration, dermal deposition appears as blue-grey discoloration, and mixed epidermal and dermal depositions appear as brown-grey discolorations [1].

The development of cosmetic lasers and other light-based devices has allowed the effective and safe treatment of many cosmetic pigmentation disorders which were previously not treatable. Such devices specifically target the pigmented lesion with minimal damage to the surrounding tissue [2].

Selective photothermolysis is the fundamental principle underlying the low-risk laser treatment of pigmented lesions. Melanin is the main chromophore in most epidermal and dermal pigmented lesions. The selective range of wavelengths for targeting melanin lies between 630 and 1100 nm, where there is good skin penetration and preferential absorption by melanin over other skin chromophores such as oxyhemoglobin and water [3].

Properly chosen wavelengths of light used with appropriate pulse durations can selectively alter pigmented cells and disrupt exogenous and endogenous pigments in a manner that leaves the adjacent skin intact and allows for the effective and safe treatment. The risk of postinflammatory hyperpigmentation can be reduced with proper patient selection, appropriate laser/light device selection, and good perioperative skin care [4].

In current practice, numerous lasers can specifically target pigmented lesions, including red-light lasers (e.g. 694-nm ruby, 755-nm alexandrite), green-light lasers (e.g. 510-nm pulsed dye, 532-nm frequency-doubled Nd:YAG), and near-infrared lasers (e.g. 1064 nm Nd:YAG). The wide range of lasers that can be used to treat pigmentation is a result of the broad absorption spectrum of melanin. Even so, other less pigment-specific lasers have been used to treat pigmented lesions, including carbon dioxide and Er:YAG lasers [5].

Intense pulsed light (IPL) treatment removes pigmentation by stimulating renewal of the upper layers of the skin from underneath, giving an effective and noninvasive alternative. The pulses of light are absorbed by the excess melanin, creating heat that destroys the uppermost pigmented skin cells, and the area is renewed after 10-14 days. The light pulse also stimulates the growth of new collagen and elastin fibers in the skin, which improves firmness and overall texture, helping to overcome the effects of sun damage. The treatments are fast, allowing the whole area or multiple areas to be treated during each session. The light pulse is very short, causing only a mild sensation during treatment. With each treatment the pigmentation fades, with removal in one to four treatments [6].

Materials and methods

Search strategy

We reviewed papers on the role of laser and IPL in the management of different types of hyperpigmented skin lesions from Medline databases (PubMed, Medscape, and Science Direct) and also from material available on the internet. We used hyperpigmentation treatment, IPL, and pigment-specific lasers as search terms. In addition, the search was performed in the electronic databases from 2003 to 2013.

Study selection

All the studies were independently assessed for inclusion criteria. They were included if they fulfilled the following criteria:

Published in English language.
Published in peer-reviewed journals.
Focused on hyperpigmentation management.
Discussed the effectiveness of different lasers and IPL on pigmented skin.
If a study had several publications on certain aspects, we used the latest publication giving the most relevant data.

Data extraction

Studies that did not fulfill the above criteria, such as studies on treatment of hyperpigmentation with topical creams, chemical peeling and dermabrasion, reports without peer-review, letters/comments/editorials/news and studies not focused on light-based therapy for hyperpigmented skin lesions were excluded.

The publications analyzed were evaluated according to evidence-based medicine criteria using the classification of the US Preventive Services Task Force and UK National Health Service protocol for evidence-based medicine in addition to the evidence pyramid.

US Preventive Services Task Force:

Level I: Evidence obtained from at least one properly designed randomized controlled trial.
Level II-1: Evidence obtained from well-designed controlled trials without randomization.
Level II-2: Evidence obtained from a well-designed cohort or case-control analytical studies, preferably from more than one center or research group.
Level II-3: Evidence obtained from multiple time series with or without intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, on the basis of clinical experience, descriptive studies, or reports of expert committees.

Quality assessment

The quality of all the studies was assessed. Important factors included the study design, attainment of ethical approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled and appropriate data analyses made in addition to an explanation for missing data.

Data synthesis

A structured systematic review was performed.

Study selection and characteristics: In total, 170 potentially relevant publications were identified: 126 articles were excluded as they did not meet our inclusion criteria. A total of 44 studies were included in the review as they were deemed eligible by fulfilling the inclusion criteria. Of these 44 articles, included in this review, 32 were laser studies and 12 were IPL studies. A study to compare efficacy and side effects of the QS alexandrite laser (QSAL) and IPL for freckle and lentigo treatment indicated that all patients experienced improvement. Postinflammatory hyperpigmentation (PIH) developed in one patient with freckles and in eight patients with lentigines after QSAL. No postinflammatory hyperpigmentation occurred after IPL. Freckles showed greater improvement after QSAL than IPL. For lentigines, the results after IPL were better than after QSAL and among those with PIH were better after QSAL [7].

A reported study of the treatment of café au lait macules in 48 Chinese patients with the Q-switched alexandrite laser found that 26 patients (51.4%) had good-to-excellent responses after an average of 3.2 treatments with a low rate of recurrence (10.4%). The results are usually favorable, and when substantial clearing is achieved, the recurrence rate is low; however, where clearance is partial, recurrence is as high as 50%. The risk of postinflammatory hyperpigmentation is as high as 50% per treatment. When this develops, it is essential to wait until it clears before resuming laser treatment [7].

Use of long-pulsed ruby and long-pulsed alexandrite lasers for Becker's nevus may offer the dual benefit of the reduction of both pigmentation and unwanted hair. In an uncontrolled study of 11 patients with skin phototype III-V, treatment with two to 12 sessions with a long-pulsed alexandrite laser led to more than 75% improvement in pigmentation in two patients (18%) and more than 50% improvement in five patients (45%). Hair density was reduced in all patients in the study [8].

Pulsed Q-switched laser surgery is unquestionably the treatment of choice for nevi of Ota and Ito, and it works through selective photothermal and photomechanical destruction of dermal melanocytes and melanophages. High success rates and minimal adverse effects have been reported with the Q-switched ruby, Q-switched alexandrite, and Q-switched Nd:YAG lasers [9].

Nevi that are predominantly localized to the epidermis and superficial dermis, such as junctional or slightly raised compound nevi, have been successfully treated with 694 nm QS ruby, 755 nm QS alexandrite, and 1064 nm QS Nd:YAG lasers in small uncontrolled studies. Congenital melanocytic nevi often extend into the deep reticular dermis, and repigmentation is likely to occur following laser treatment. Since some nevus cells typically remain recurrence is possible [10].

A combination treatment with Kligman's triple combination formula (2% hydroquinone, 0.025% tretinoin, and 1% mometasone) started at least 8 weeks prior to laser treatment (1064-nm Q-switched Nd:YAG) was reported to be effective for melasma treatment, with no adverse effects [11].

The 1064 nm QS Nd:YAG laser may have benefits for postinflammatory hyperpigmentation. In a nonrandomized comparison study of 40 Korean patients with acne and postinflammatory hyperpigmentation, 11 out of 20 patients given five weekly treatments with a 1064 nm QS Nd:YAG laser with low fluence had more than 50% improvement in hyperpigmentation, while no patients who were excluded from laser therapy achieved similar results [12].

Moreno Arias and Ferrando in their study of IPL and melanocytic lesions, treated two patients with epidermal melasma and achieved 76-100% clearance with a 590 nm cutoff filter, fluence of 34 J/cm ² , pulse width of 3.8 ms, double mode, and pulse delay of 20 ms. However, three patients with mixed melasma showed less than 25% clearance with a 615 nm cutoff filter, fluence of 38 J/cm ² , pulse width of 4.5 ms, double mode, and pulse delay of 20 ms. Patients developed PIH [13].

In a case report, an IPL device was successfully used to treat pigmentation due to stasis dermatitis secondary to chronic venous insufficiency. The normal skin color was restored, no repigmentation was observed within the 6 months of follow-up, and no side effects occurred [14].

Discussion

This is a systematic review of the literature focuses on the benefits derived from application of laser and IPL in the treatment of hyperpigmentation. This is a timely and relevant report because of the increasing number of laser and IPL types in addition to the large number of patients who followed up for recurrence or appearance of side effects.

Hyperpigmentation typically results from increased melanin, which may occur in the epidermis, dermis, or both. Typically, this happens either by increased melanin production by existing melanocytes or from proliferation of active melanocytes. Normally, the melanocytes are located in the basal layer of the epidermis and an increase in number or activity will cause epidermal hyperpigmentation. However, formed melanin may be transferred to the dermis or, in some cases, dermal melanocytes maybe present. A heightened activity or increased number of melanocytes in these instances will lead to dermal hyperpigmentation. Also, a combination of both may take place, triggering mixed hyperpigmentation [15].

Selective photothermolysis is the fundamental principle underlying the low-risk laser treatment of pigmented lesions. Melanin, the main chromophore in most epidermal and dermal pigmented lesions, has a broad absorption spectrum extending from the UV range to the visible and infrared spectra. The selective range of wavelengths for targeting melanin lies between 630 and 1100 nm, where there is good skin penetration and preferential absorption by melanin over other skin chromophores such as oxyhemoglobin and water. Pigment specificity of lasers and light devices is dependent on both the wavelength and the pulse width [16].

The development of cosmetic lasers and other light-based devices has allowed for the effective and safe treatment of many cosmetic pigmentary disorders which were previously not treatable. Such devices specifically target the pigmented lesion with minimal damage to the surrounding. Several pigment-specific lasers can effectively treat epidermal and dermal pigmented lesions. Lasers are most effective in treating epidermal pigmented lesions (e.g. lentigines, ephelides). Variable responses can be expected in café au lait macules, Becker nevi, nevus spilus, and melasma. Nevus of Ota is unique in that near-total clearance is often seen after laser treatment. New, long-pulsed, pigment-specific lasers may further enhance the clinical results obtained for resistant pigmented lesions and other conditions [17].

In general, epidermal pigmentation is easier to eradicate than dermal pigmentation because of its proximity to the skin surface. Several lasers can effectively treat epidermal lesions. These include the Q-switched laser systems, pulsed visible light lasers, CW lasers, and CO ₂ or erbium lasers. The goal is to remove unwanted epidermal pigmentation, and as long as the injury is above the dermal-epidermal junction, most cases will heal without scarring [18].

The development of Q-switched lasers has revolutionized the treatment of dermal melanocytosis. The dendritic cells found deep in the dermis are particularly sensitive to short-pulsed laser light, frequently resulting in complete lesional clearing without unwanted textural changes [5].

Although undesired, complications are a reality with clinical application of lasers and light-based therapy. It is imperative that all operators be aware of the spectrum of adverse effects and complication profile specific to each laser and energy source before use. These complications should be discussed in detail with patients and a full informed consent should be taken before the procedure [19].

Awareness of the varying responses, and varying risks, between skin types may spare the physician and patient unwanted side effects from these treatments, most especially patients with darker skin types. In addition, consistent use of a proper surgical technique with every procedure and investing time to educate all patients regarding the post-treatment recovery period will ensure optimal healing conditions, and ultimately, minimize risk of complications [20].

The advent of IPL devices in the early 1990s signaled a paradigm shift in the concept of light-based skin rejuvenation including treatment of many acquired superficial pigmentary disorders. Instead of targeted removal of a single skin lesion by a specific laser light, the use of an intense, pulsed, broadband light emitted by a noncoherent flashlamp with filters to modulate the wavelengths allowed for simultaneous treatment of multiple skin blemishes [21].

The working of the IPL devices is based on the principle of selective photothermolysis, in which thermally mediated radiation damage is confined to chosen epidermal and/or dermal pigmented targets at the cellular or tissue level. This thermal heating induces rapid differentiation of keratinocytes. This process results in an upward transfer of melanosomes along with necrotic keratinocytes, resulting in their elimination as micro crusts that are removed from the skin surface. Tissues surrounding these targeted structures, including overlying or immediately neighboring cells, are spared, potentially reducing nonspecific, widespread thermal injury [22].

The effect of IPL treatment on pigmentation is cumulative and repeat treatments (typically 3-6) every 3-4 weeks are generally necessary for complete clearance. IPL devices have shown to be highly effective in the treatment of photodamaged pigmented lesions like solar lentigines, and generalized dyschromia. As expected, darker lesions and those where the pigment is localized to deeper layers of the dermis typically respond slowly and require a higher total number of treatments. In these cases, despite adequate treatment regimens, lesions are often persistent [23].

Patient's rapid recovery time is one of the greatest advantages of the IPL treatment. Further advantages of using lasers are lower purchase price, large spot size, high skin coverage rate, high versatility, and robust technology. Greater covered area and more uniform light penetration are achieved by selection of a bigger spot size. However, the main disadvantage of IPL is the lack of adequate skin cooling which can lead to a higher risk of complications in dark-skinned patients if not used correctly but recent IPL devices (e.g. Kalon, P-NAIN) revealed good results for such high risk cases of complications by cooling the skin contact surface of the IPL handpiece [24].

Conclusion

Progress in laser and IPL technology has involved the development of safer and more efficient methods of achieving the desired effects on skin problems. The Q-switched lasers (532 nm FD Nd:YAG, 694 nm Ruby, 755 nm Alexandrite, or 1064 nm Nd:YAG) with their high peak power and pulse width in the nanosecond range are best suited to treat various epidermal, dermal, and mixed lesions. Long-pulsed ruby and alexandrite lasers have been shown to be effective in the treatment of Q-switched ruby laser-resistant congenital nevi and other pigmented lesions. Nonablative fractional photothermolysis holds great promise in treatment of both pigmentary variation as well as skin textural abnormalities (acne scarring, rhytides, and skin mottling associated with photoaging). Intense pulsed technology is a highly versatile, safe, and effective modality for the treatment of pigmented lesions.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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